Getting hurt on the job is bad enough…
Mounting medical bills. Discontinued paychecks. And then a letter arrives, notifying you that the claim was denied.
It can feel like a nightmare.
The good news is a denial is NOT the final word. In fact, most denials are overturned once the workers follow the proper procedure. The appeal process is in place for a reason – to allow injured workers another opportunity to obtain the benefits they are entitled to.
This article breaks down how the appeals process works and how to fight back.
Here’s what’s covered:
- Why Workers’ Comp Claims Get Denied
- How The Appeals Process Works
- Building A Strong Appeal
- Wage Loss Benefits And The Appeal
- When To Hire A Lawyer
Why Workers’ Comp Claims Get Denied
Denials are more common than you might realize. Somewhere between 7% and 13% of claims are initially denied in the US – that’s hundreds of thousands of workers every single year.
Here are the top reasons for denial:
- Missed deadlines: The injury was not reported quickly enough or the claim was filed too late.
- Pre-existing conditions: The insurer blames your injury on an old problem.
- Weak medical evidence: The doctor failed to connect the injury to the job sufficiently.
- Lack of witnesses: Nobody saw the accident happen.
- Workplace disputes: The employer argues you were not “on the clock.”
The insurance company only wants to pay out as little as possible. So they’ll find any excuse to deny a claim.
That’s why getting a good Minneapolis worker’s compensation attorney on your side is often the smartest decision you can make. Wage loss benefits can replace a substantial portion of your lost income while you heal – but only if your claim is approved. An attorney knows exactly what the insurance company is looking for and how to fight aggressively when they refuse you.
How The Appeals Process Works
Every state has its own appeals process…
But most of the process is actually the same. This is a typical path for most workers:
Step 1: Read The Denial Letter Carefully
The denial letter will explain:
- Why the insurer rejected the claim
- What your appeal rights are
- The exact deadline to file an appeal
Do not discard this letter. In most states, there are only 30 days in which to take action – if you fail to meet that deadline, your right to appeal will be forever lost.
Step 2: File A Formal Appeal
You must file a petition, application, or request for hearing (states use different terms) with your state’s workers’ comp agency. This starts the appeal process.
Step 3: Attend Mediation
In some states there will be a mediation/informal settlement meeting before the case is heard. This is an opportunity for the case to be settled without a formal hearing. Both sides will work with a neutral mediator to try to reach an agreement.
Step 4: Go To A Hearing
If mediation is unsuccessful, your case is scheduled for a hearing before a workers’ compensation judge. You present evidence, call witnesses and make arguments on your behalf. The judge makes a decision on your entitlement to benefits.
Step 5: Higher Appeals
You can still appeal to a higher board and even a state court if the judge rules against you. The process can take months (or longer), but many workers win at these later stages.
Building A Strong Appeal
Appeals succeed or fail based on evidence. Period.
Preparation is key. Studies have found that 67% of denied claims are paid within one year when the workers put up a proper fight.
Key evidence to gather:
- Medical records: Every report, every test, every note from every doctor.
- Second opinions: Independent medical exams to counter the insurer’s doctor.
- Witness statements: Written accounts from coworkers who saw the accident.
- Accident reports: The initial incident report filed with the employer.
- Employment records: Job descriptions, time sheets, and performance reviews.
The thicker your paper trail the more difficult it is for the carrier to deny.
Also – record the ways the injury affects your everyday life. Keep a journal of pain, treatment visits, and how the injury impacts your regular activities. The little details are very important at a hearing.
Wage Loss Benefits And The Appeal
Wage loss benefits are often the biggest thing at stake in an appeal.
Workers’ compensation benefits will be provided to you when you cannot work due to an occupational injury. The two primary forms of benefit are:
- Temporary Total Disability (TTD): Paid when you can’t work at all during recovery.
- Temporary Partial Disability (TPD): When you return to work but make less money because of the injury.
Workers’ comp usually provides about two-thirds of the average weekly wage. The actual amount varies by state.
Here is the critical part…
You get nothing. No wage loss benefits. No medical coverage. If the claim is denied, that is why the appeal is so important.
The average award on appeal is 55% higher than the original claim amount. That’s a big number – and compelling evidence that an appeal is 100% worth the fight.
When To Hire A Lawyer
It’s possible to represent yourself during an appeal. However, statistics demonstrate that appealants are much more likely to win when they’re represented by counsel.
Workers who hire attorneys for denied claims get an average of 47 percent more in benefits. That’s about $18,200, compared with $12,400 for those who go unrepresented.
A good workers’ comp lawyer will:
- Review the denial letter and spot weak points
- Gather the right medical evidence
- Handle all paperwork and deadlines
- Represent you at mediation and hearings
- Negotiate settlements with the insurer
The vast majority of workers’ comp attorneys charge on a contingency basis. This means you pay no fees upfront – the only time they get paid is when you win. This means there is absolutely no financial risk to you for getting assistance.
First consultations are also almost always free.
The Bottom Line
A denied workers’ comp claim is frustrating, stressful and scary. But it is absolutely not the end of the story.
The appeals process provides you with genuine opportunities for a reversal of fortune. If you can marshal the necessary evidence, pay close attention to the deadlines, and get some quality legal assistance, you can secure the wage loss benefits, medical treatment, and compensation to which you are entitled.
To quickly recap:
- Read the denial letter carefully
- File the appeal on time
- Gather strong medical and witness evidence
- Take full advantage of mediation
- Consider hiring a lawyer – the stats clearly show it pays off
Remember – denials get overturned every single day. Your claim could be next.
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